Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected the care and services they received. For one resident with a diagnosis of congestive heart failure, physician orders indicated the use of oxygen therapy as needed for shortness of breath, and the resident was observed receiving oxygen therapy at the bedside. However, the MDS assessment did not document the use of oxygen therapy. The MDS nurse confirmed that the physician order and observation supported the use of oxygen, but this was not reflected in the MDS. For another resident with a history of seizures and severe cognitive impairment, physician orders and the Medication Administration Record (MAR) showed the resident was receiving anticonvulsant and anti-anxiety medications. Despite this, the MDS assessment did not indicate the use of these medications. The MDS nurse acknowledged that the MDS failed to document the resident's use of anti-anxiety and anticonvulsant medications, which was inconsistent with the resident's medical records and medication administration history. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations.